Good Showing for Robotics in Gastric Cancer

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Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

This study retrospectively compared the outcomes in patients treated with either robotic gastrectomy or laparoscopic gastrectomy and found that there was no difference in the overall survival or relapse survival between the two groups.

SAN FRANCISCO -- Patients with nonmetastatic gastric cancer had similar survival and other outcomes following robotic or conventional laparoscopic gastrectomy, according to a large retrospective series from Korea.

Both surgical techniques led to a 5-year survival of 94% and disease-free survival (DFS) of 92%. Survival also did not differ significantly by disease stage, according to Woo Jin Hyung, MD, PhD, of Yonsei University in Seoul.

However, the 800-patient series did not address functional outcomes, quality of life, or cost, and primarily included patients with earlier-stage disease, he reported here at the Gastrointestinal Cancers Symposium.

"Robotic assistance in gastrectomy for gastric cancer is associated with acceptable long-term oncologic outcomes and is an effective alternative with satisfactory short-term outcomes," said Hyung. "Robotic surgery might be an easy way to extend the indication for minimally invasive surgery for gastric cancer."

Robotic surgery has become a standard of care for some procedures, notably prostatectomy and hysterectomy. Robotics offers certain advantages that could make it attractive for gastrointestinal surgery, said Hyung. Robotic assistance can make complex and advanced minimally invasive surgery procedures less difficult, and possibly lessen the learning curve for advanced procedures.

General surgeons, however, have been slower to warm up to robotics as compared with their colleagues in urology and gynecology, he acknowledged.

Initial studies of robotics in gastric cancer has shown that the technique is feasible and associated with morbidity and mortality similar to those of conventional laparoscopic surgery. In particular, both techniques have demonstrated comparable oncologic outcomes, said Hyung.

Investigators have reported less blood loss and shorter hospital stays with robotic-assisted gastric procedures. Most surgeons who have pursued robotics for gastric cancer have found the learning curve to be about 10 cases, as compared with about 15 cases for laparoscopic gastrectomy, he continued.

Consistent with findings in other surgical specialties, robotic-assisted gastrectomy is more costly and takes longer to complete.

Cost-effectiveness has yet to be examined in detail, said Hyung, nor have the long-term oncologic results.

Long-term oncologic outcomes were the focus of a retrospective evaluation of patients who underwent laparoscopic or robotic-assisted gastrectomy for stages T1-T3 gastric cancer. Outcomes of interest included recurrence rates and patterns and operative outcomes, in addition to overall survival and DFS.

The analysis included 837 patients treated between 2005 and 2009 with robotic (N=313) or conventional laparoscopic gastrectomy (N=524). Hyung noted that South Korean patients must pay the difference in cost if they opt for a robotic-assisted procedure.

Most patients with stage II or more advanced gastric cancer received 5 FU-based adjuvant chemotherapy. The study covered a median follow-up of 50 months.

Patients who opted for robotic-assisted gastrectomy were younger (54.5 versus 59.3, P<0.001) and more likely to undergo total resection (27% versus 20%, P=0.016). Robotic procedures required an average of 219 minutes to complete compared with 149 minutes for laparoscopic procedures (P<0.001).

Following robotic surgery, 5.4% of patients had recurrences compared with 3.6% of patients in the laparoscopic group, a nonsignificant difference that Hyung suggested could have reflected the imbalance in stage distribution. Analysis of recurrence by stage and site also showed no significant differences between the groups.

In a multivariate analysis of overall survival, significant predictors were age (P=0.002), sex (P=0.006), and nodal status (P<0.001). Type of surgery did not influence survival (P=0.144).

Invited discussant Donald Low, MD, said the study has several notable strengths, including similarity of the two patient groups, low rates of conversion and operative mortality, and "outstanding" oncologic outcomes in both groups.

The trial also had several weaknesses, particularly the absence of comparative data on functional outcomes, cost, and cost-effectiveness.

"Quite frankly, in this day and age, when you're doing a major extirpative surgical procedure, you should be at least looking at some aspect of functional outcomes," said Low, of Virginia Mason Medical Center in Seattle.

Total hospital charges were almost $5,000 greater for robotic procedures, and patients had to pay an average of $11,540 if they opted for robotic surgery compared with $3,956 for laparoscopic surgery. Hospital profit averaged $689 per procedure with robotics versus $1,671 when the surgery was performed laparoscopically.

Cost issues in oncologic applications of robotic surgery have been studied and reported extensively, including at least a half dozen publications in 2012 alone. The studies have consistently shown:

Comparable outcomes in laparoscopic and robotic patient populations

High initial cost of robotic systems

Higher instrumentation costs associated with robotics systems

Higher maintenance costs with robotics versus laparoscopic surgery

"Robotic surgery is equivalent to -- but not better than -- laparoscopic surgery for major cancer procedures," said Low. "Robotic gastrectomy currently provides no measurable outcome benefits and is likely significantly more expensive."

Evaluation of robotic performance in oncologic procedures is complicated by several confounding issues, he added. The cost should decrease and results become more consistent in high-volume centers. Currently, no competition exists in the robotic systems market. Operators have accumulated minimal long-term outcome data.

"Future randomized or controlled studies of the application of robotic operations in major cancer surgery must assess technical and outcome advantages -- not equivalency but advantages -- quality of life and functional outcomes and, ultimately, the holy grail -- cost-effectiveness," Low said.

Hyung and colleagues had no relevant disclosures.

Low disclosed a relationship with Boston Scientific.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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